Developments in the correction of presbyopia II: surgical approaches

Jacobi-Fourier phase masks as ophthalmic elements to correct presbyopia

PURPOSE

Investigations into the correction of presbyopia have considered lens design, clinical implications and the development of objective metrics such as the visual Strehl ratio. This study investigated the Jacobi-Fourier phase mask as an ophthalmic element in the correction of presbyopia. The goal was to develop a contact or intraocular lens whose performance was largely insensitive to changes in pupil diameter.

METHODS

Numerical simulations based on Fourier optics were performed to evaluate three different Jacobi-Fourier polynomials, with the aim of providing a range of clear vision (1 Dioptre (D)). Performance was evaluated for three pupil sizes (6, 4 and 2 mm), while polychromatic images were simulated using three different wavelengths (656.3, 587.6 and 486.1 nm). The Neural Transfer function was included in the simulation. To validate the method and results, we used the Visual Strehl combined objective metric (VSCombined) currently used in visual optics. This metric gives more weight to the phase transfer function and is more suitable for non-symmetrical phase functions.

RESULTS

Numerical validation showed the suitability of the Jacobi-Fourier phase masks for extending the range of clear vision of presbyopic eyes, providing a visual acuity of at least 0.10 logMAR (6/7.5 Snellen) at all distances between 1 and 6 m. The results show a range of clear vision of 1D was not affected by changes in pupil size, an increase in retinal image contrast accompanied by image artefact reduction by increasing the radial order of the Jacobi-Fourier phase mask and a reduction of wavelength dependence of the retinal images. These results are supported by simulated images and the objective criterion VSCombined.

CONCLUSIONS

The use of Jacobi-Fourier phase masks as ophthalmic elements for presbyopic correction show promising results, with a good range of clear vision and reduced dependence on pupil size and chromatic aberration.

BCLA CLEAR Presbyopia: Definitions

Presbyopia is often the first sign of ageing experienced by humans. Standardising terminology and adopting it across the BCLA CLEAR Presbyopia reports, improves consistency in the communication of the evidence-based understanding of this universal physiological process. Presbyopia can be functionally and psychologically debilitating, especially for those with poor access to eyecare. Presbyopia was defined as occurring when the physiologically normal age-related reduction in the eye's focusing range reaches a point that, when optimally corrected for far vision, the clarity of vision at near is insufficient to satisfy an individual's requirements. Accommodation is the change in optical power of the eye due to a change in crystalline lens shape and position, whereas pseudo-accommodation is the attainment of functional near vision in an emmetropic or far-corrected eye without changing the refractive power of the eye. Other definitions specific to vision and lenses for presbyopia were also defined. It is recommended that these definitions be consistently adopted in order to standardise future research, clinical evaluations and education.

BCLA CLEAR Presbyopia: Evaluation and diagnosis

It is important to be able to measure the range of clear focus in clinical practice to advise on presbyopia correction techniques and to optimise the correction power. Both subjective and objective techniques are necessary: subjective techniques (such as patient reported outcome questionnaires and defocus curves) assess the impact of presbyopia on a patient and how the combination of residual objective accommodation and their natural DoF work for them; objective techniques (such as autorefraction, corneal topography and lens imaging) allow the clinician to understand how well a technique is working optically and whether it is the right choice or how adjustments can be made to optimise performance. Techniques to assess visual performance and adverse effects must be carefully conducted to gain a reliable end-point, considering the target size, contrast and illumination. Objective techniques are generally more reliable, can help to explain unexpected subjective results and imaging can be a powerful communication tool with patients. A clear diagnosis, excluding factors such as binocular vision issues or digital eye strain that can also cause similar symptoms, is critical for the patient to understand and adapt to presbyopia. Some corrective options are more permanent, such as implanted inlays / intraocular lenses or laser refractive surgery, so the optics can be trialled with contact lenses in advance (including differences between the eyes) to better communicate with the patient how the optics will work for them so they can make an informed choice.

Visual performance, safety, and patient satisfaction after binocular clear lens extraction and trifocal intraocular lens implantation in Chinese presbyopic patients

BACKGROUND

Addressing presbyopia in the aging population, particularly in non-cataractous patients, remains a challenge. This study evaluates the outcomes of refractive lens exchange (RLE) with AT LISA tri 839MP trifocal intraocular lens (IOL) implantation in a Chinese presbyopic population without cataracts.

METHODS

The study included 164 eyes from 82 patients undergoing bilateral RLE at Peking Union Medical College Hospital. Comprehensive evaluations encompassed visual acuities, refraction, ocular aberrometry, and subjective outcomes via the VF-14 questionnaire. The focus was on postoperative visual performance, refractive outcomes, safety, objective optical quality, and patient satisfaction.

RESULTS

100%, 90.2%, and 89.0% of patients achieved binocular UDVA, UNVA, and UIVA of logMAR 0.1 or better at 6 months postoperatively. 97.6% of eyes were within ± 1.00 D of emmetropia postoperatively. Optical quality assessments showed increases in modulation transfer function and Strehl ratios (p < 0.05). High-order aberrations decreased significantly (p < 0.05). Despite the high incidence of posterior capsule opacification (83.2%), managed with early Nd: YAG capsulotomy, no other severe complications were reported. Patient-reported outcomes indicated high satisfaction, with an average VF-14 score of 94.3 ± 10.2 and 93.5% achieving complete spectacle independence. Halo (66.2%) was the most commonly reported optical phenomena, followed by glare (18.2%), and starburst (7.8%) after surgery.

CONCLUSIONS

Bilateral RLE with trifocal IOLs in presbyopic patients without cataracts significantly improves visual acuity and reduces ocular aberrations in presbyopic patients. The procedure offers high patient satisfaction and spectacle independence, though it requires careful patient selection and management of expectations regarding potential photic phenomena.

Effects of Miosis on the Visual Acuity Space under Varying Conditions of Contrast and Ambient Luminance in Presbyopia

Background: Presbyopia is an age-related ocular condition, typically affecting individuals aged over 40 years, characterized by a gradual and irreversible decline in the eye's ability to focus on nearby objects. Correction methods for presbyopia encompass the use of corrective lenses, surgical interventions (corneal or lens based), and, more recently, the FDA-approved topical administration of 1.25% pilocarpine. While prior research has demonstrated the efficacy of daily pilocarpine eye drop application in enhancing near visual acuity by increasing the depth of focus leveraging the pinhole effect, limited knowledge exists regarding its influence on visual acuity under varying conditions of contrast and ambient luminance. Methods: This study aims to investigate the impact of these variables on visual acuity, employing the VA-CAL test, among 11 emmetropic and 11 presbyopic volunteers who reported subjective difficulties with near vision. This study includes evaluations under natural conditions with a pinhole occluder (diameter of 2 mm), and subsequent administration of 1% pilocarpine (Pilomann, Bausch + Lomb, Laval, Canada). Results: The VA-CAL results demonstrate the expected, statistically significant effects of contrast and ambient luminance on visual acuity in both emmetropic and presbyopic volunteers. Furthermore, in emmetropic individuals, the application of pilocarpine resulted in a statistically significant reduction in visual acuity. In contrast, presbyopes did not exhibit statistically significant differences in the visual acuity space under either the pinhole or pilocarpine conditions when compared to natural conditions. Conclusions: The pharmacological treatment of presbyopia with pilocarpine eye drops, intended to enhance near vision, does not adversely affect visual acuity in presbyopes. This suggests that pilocarpine may offer a viable alternative for individuals averse to wearing corrective eyewear.

Blazed photon sieve for the correction of presbyopia

What we believe to be a new type of transparent photon sieve is presented with application for presbyopia correction. Inspired by blazed gratings, we propose to design an intracorneal implant with slanted holes. The slopes introduce a new degree of freedom, breaking the symmetry of energy distribution along the optical axis and allowing to balance the energy between near and far vision. This new implant design is presented together with the simulation, manufacturing and validation methods. The first experimental results obtained with an implant manufactured in a biocompatible material are presented confirming the potential of the approach.

A comparative evaluation of three extended depth of focus intraocular lenses

PURPOSE

To compare the refractive and visual performance of three Extended Depth of Focus (EDOF) intraocular lenses (IOLs) after uncomplicated cataract surgery.

SETTING

Centre IRIDIS, Albi, France.

DESIGN

Comparative retrospective study.

METHODS

Patients with cataracts and without other eye diseases were enrolled for monocular implantation of EDOF IOLs on the dominated eye by the same surgeon between 2018 and 2021, using either the IsoPure (BVI-PhysIOL, Belgium), the Synthesis+ (Cutting Edge, France), or the Lucidis (SAV-IOL, Swiss). Refraction, Uncorrected Distance Visual Acuity (UDVA), Corrected Distance VA (CDVA), Uncorrected Near VA (UNVA), Distance-Corrected Near VA (DCNVA), 25% Contrast CDVA, and Defocus Curve were assessed 3-months postoperatively.

RESULTS

A total of 64 eyes of 64 patients were included in this study (IsoPure n = 22; Synthesis+ n = 20, Lucidis n = 22). CDVA, 25% Contrast CDVA and DCNVA were significantly better for Lucidis than IsoPure or Synthesis+. No significant difference was observed for CDVA and 25% Contrast CDVA between IsoPure and Synthesis+. DCNVA was significantly better for Lucidis and Synthesis+ with respectively 0.08 LogMAR ± 0,09 and 0.29 LogMAR ± 0.13, compared to 0.40 LogMAR ± 0.17 for IsoPure (p < 0.05).

CONCLUSIONS

Lucidis showed more efficient distance, low contrast, and near vision than IsoPure and Synthesis+. Synthesis+ seems to be more efficient in intermediate vision than other groups. Each EDOF IOLs provided good distance vision without creating spontaneous complaints of photic phenomena. Refractive EDOF IOLs, especially Lucidis, are efficient for patients wishing to improve their vision without dysphotopsia.

Optical Performance of a Segmented Extended-Depth-of-Focus Intraocular Lens under the Influence of Different Values of Spherical Aberration Generated by Refractive Surgery

BACKGROUND

Corneal refractive surgery induces high-order aberrations, specifically spherical aberration (SA). These aberrations can have implications when patients later develop cataracts and require the implantation of multifocal intraocular lenses (MIOLs). MIOLs with asymmetric designs pose challenges in predicting outcomes, particularly in these cases. The aim of this study was to evaluate how different values of SA, resulting from various types of refractive surgeries, affect the optical performance of the FEMTIS Comfort intraocular lens.

METHODS

The through-focus modulation transfer function (TF-MTF) curve and high-contrast images of tumbling E were used as parameters to assess the optical performance of the MIOL. These parameters were measured using an adaptive optics visual simulator.

RESULTS

Increasingly negative values of SA make the MIOL more bifocal, moderating its extended-depth-of-focus characteristic. Conversely, higher positive SA values cause the TF-MTF curve to shift towards positive vergences, leading to worsened distance vision in the +1.00 to +2.00 D range, but improved vision in the +0.50 D to +1.00 D range.

CONCLUSIONS

Assessing SA in patients prior to implanting MIOLs with asymmetric designs is necessary for predicting outcomes and making informed decisions based on the visual requirements of patients.

Comparison of the Polychromatic Image Quality of Two Refractive-Segmented and Two Diffractive Multifocal Intraocular Lenses

Evaluating chromatic aberration for a multifocal intraocular lens (MIOL) in vitro is essential for studying its performance because it helps determine the most appropriate lens for each patient, enhancing surgical outcomes. While refractive MIOLs with angular power variation have shown positive clinical outcomes, studies of these MIOLs on optical benches primarily employed monochromatic green light, neglecting the impact of longitudinal chromatic aberration (LCA) on MIOL performance. To address this gap, we evaluated the through-focus modulation transfer function (TF-MTF) and the point spread function (PSF) of two refractive segmented extended depth of focus intraocular lenses (IOLs) (Femtis Comfort and Precizon Presbyopic), comparing the results with those obtained with two widely known diffractive multifocal intraocular lenses (AcrySof IQ ReSTOR and FineVision Pod F). Measurements of the TF-MTF were conducted using both monochromatic and polychromatic light in a customized optical bench. The refractive designs exhibited distinct haloes in the PSFs. When comparing the refractive and diffractive designs, opposite signs of LCA were observed at near foci. These findings emphasize the influence of the optical design of IOLs on their performance under polychromatic light, providing valuable information for vision care professionals when selecting the most suitable lens for each patient.

Effect of postoperative residual astigmatism on visual outcomes after trifocal intraocular lens implantation

Purpose

The aim of this study was to evaluate the effect of residual astigmatism on postoperative visual outcomes after trifocal intraocular lens implantation.

Methods

In this prospective observational study, we divided 156 eyes into two groups according to postoperative astigmatism measured by subjective optometry and followed them up for 3 months. Visual acuity, modulation transfer function (MTF) curves, Strehl ratio (SR), Visual Function Index-14 scores, and photic phenomena were compared.

Results

Linear regression analysis revealed a weak correlation between residual astigmatism and uncorrected distance visual acuity (UDVA) (r = 0.190, P = 0.016) at 3 months and a significant between-group difference at 1- and 3-month postoperative UDVA (P = 0.038, P = 0.018, respectively). MTF curve values and SR (MTF-10 total, MTF-10 cornea, MTF-30 total, MTF-30 cornea, SR Total, and SR cornea) were significantly worse (P < 0.001), and the Visual Function Index-14 scores were lower in the 0.5 < astigmatism ≤ 1.25 D group (P < 0.05) than in the astigmatism ≤ 0.5 D group. No significant differences were found in the frequency, severity, and bothersomeness of photic phenomena (P > 0.05).

Conclusion

Postoperative residual astigmatism affects the UDVA of the trifocal intraocular lens-implanted eyes. Although we found no significant differences in uncorrected intermediate and near visual acuity, both objective and subjective visual quality were affected, suggesting the need for surgical planning when the anticipated postoperative astigmatism is >0.5 D.

Bilateral Implantation of Multifocal Intraocular Lenses: 10-Year Follow-Up

PURPOSE

To evaluate and compare the long-term results after bilateral implantation of different multifocal intraocular lenses (MIOLs).

METHODS

This retrospective comparative study included 42 patients who underwent cataract surgery with bilateral MIOL implantation. Patients were divided into 5 groups: Group 1 received a refractive ReZoom NGX1 IOL (AMO), Group 2 a diffractive Acrysof ReSTOR SA60D3 IOL (Alcon), and Group 3 a diffractive Tecnis ZM900 IOL (AMO). Group 4 and Group 5 were implanted using the mix and match approach with refractive ReZoom-diffractive ReSTOR IOL and refractive ReZoom-diffractive Tecnis ZM900 IOL, respectively. Primary outcome measures were distance, near, and intermediate distance visual acuity measured 6 months (T0) and 10 years (T1) after surgery. Secondary outcomes were defocus curves, contrast sensitivity, patients' satisfaction, and spectacle independence.

RESULTS

All patients achieved best-corrected distance visual acuity (BCDVA) greater than 0.11 logMAR and uncorrected distance visual acuity (UCDVA) greater than 0.14 logMAR at both time points. A decrease in contrast sensitivity was evident, particularly at high spatial frequencies; at T1, Group 4 reported statistically higher values than Group 2 at 12 cycles/degree and 18 cycles/degree and statistically higher values than Group 3 at 18 cycles/degree. Great overall satisfaction was reported even in the presence of dysphotopsia. Tecnis ZM900 IOL showed the lowest incidence of posterior capsular opacification.

CONCLUSION

MIOLs could provide adequate functional vision and patient satisfaction, despite the incidence of side effects, in carefully selected patients desiring spectacle independence.

Impact of personality on the decision process and on satisfaction rates in pseudophakic presbyopic correction

PURPOSE

To explore the impact of personality on the decision process and satisfaction rates in pseudophakic presbyopic correction.

SETTING

Department of Ophthalmology, University Hospital of Alexandroupolis, Greece.

DESIGN

Prospective, comparative study.

METHODS

A consistent consultation was conducted in patients with cataract that explained the benefits and the drawbacks of bilateral trifocal correction, which was offered at no extra cost. In all participants, personality was evaluated by The Traits Personality Questionnaire 5. Data modeling with decision trees and multiple regression analysis identified the contributions of personality traits to the decision process and postoperative satisfaction.

RESULTS

Of 120 participants (60 men and 60 women), 81 (67.5%, 24 men, 57 women) selected premium correction. In men, low neuroticism and high extraversion were the primary personality contributors for selecting premium surgery. In women, all personality traits contributed to the selection process. Women were more demanding in the expected postoperative distant acuity than men (0.1 vs 0.2 logMAR) to present high satisfaction. For both men and women, openness to experience, conscientiousness, and extraversion are primary contributors for optimal satisfaction rates.

CONCLUSIONS

Men and women demonstrate differences in the selection process for premium pseudophakic surgery and differences in the expected postoperative visual acuity. It seems that the personality of the patient plays a significant role in the perceived outcome after premium surgery.

Multifocal contact lens vision simulated with a clinical binocular simulator

PURPOSE

The purpose of this study is to compare the binocular visual perception of participants wearing multifocal contact lenses and these same lens designs viewed through a temporal multiplexing visual simulator.

METHODS

Visual performance and perceived visual quality at various distances were obtained in 37 participants wearing soft M-CLs and through the SimVis Gekko programmed with the same lenses. In a pilot study (n = 10) visual performance was measured in terms of LogMAR visual acuity (VA) at far (4 m), intermediate (64 cm) and near (40 cm) distances and through-focus VA (TFVA) curves with the simulated M-CLs. In the follow-up study (n = 27), LogMAR VA at far, intermediate and near distances were measured both with the actual and simulated M-CLs. Perceived visual quality was measured in both studies using the Multifocal Acceptance Score (MAS-2EV), and a Participants Reported Outcomes Vision questionnaire. Differences between the metrics obtained with simulated and actual lenses were obtained.

RESULTS

Both actual and simulated M-CLs increased depth-of-focus by a similar amount. Mean LogMAR VA differences with actual and simulated M-CLs ranged between 4 and 6 letters (0.08 ± 0.01, 0.12 ± 0.01 and 0.10 ± 0.01, for far, intermediate and near distances, respectively). MAS-2EV average score differences with actual and simulated M-CLs ranged between -1.00 and + 4.25. Average MAS-2EV scores were not correlated significantly with VA. However, MAS-2EV (average and individual scores) were highly correlated to visual quality questionnaire responses (p < 0.005).

CONCLUSIONS

A simultaneous vision simulator accurately represented vision with M-CLs both VA at various distances and perceived visual quality, as measured in a clinical setting. The MAS-2EV metric accurately captured participant reported outcomes of standard vision questionnaires. The combination of SimVis Gekko and MAS-2EV has the potential to largely reduce chair time in M-CLs fitting.

Pharmacological treatment of presbyopia: A systematic review

The aim of this study was to identify the efficacy of drug agents for pharmacological Treatment of Presbyopia. Published research papers were reviewed using the relevant terms in PubMed, Science direct, Google scholar, Medline, Google patent, Ovid, Cochrane Database of Systematic Reviews, Scopus. In the initial search, 2270 records were obtained. By removing duplicate articles and all articles that did not meet the inclusion criteria or were inappropriate due to indirect relevance to the subject, 44 studies were selected. It should be noted that all studies had inclusion criteria. There are a number of topical pharmacological agents available for treating presbyopia such as FOV Tears and PresbiDrop. They consist of parasympathetic agent and non-steroidal anti-inflammatory drugs (NSAIDs), to contract the ciliary and pupil muscle and restore the accommodation. Another example of topical pharmacological agent is EV06. It is a lens-softening eye drop which can affect the rigid lens in presbyopia. Currently there is no pharmacological agent available to treat presbyopia. Although there are limited number of peer-reviewed articles available, the outcome for future agents under investigation are promising.

Visual performance, safety and patient satisfaction after bilateral implantation of a trifocal intraocular lens in presbyopic patients without cataract

Background

The aim was to evaluate the safety and efficacy of a trifocal intraocular lens (IOL) for the correction of presbyopia and to assess patient satisfaction.

Methods

Records from three centres were reviewed to select presbyopic patients having undergone bilateral refractive lens exchange and implantation of the AT LISA tri 839MP multifocal IOL. Postoperatively, monocular and binocular distance, intermediate and near visual acuities, corrected and uncorrected, and subjective refraction were measured. Patients also completed a quality of life questionnaire. Safety evaluation included IOL stability and postoperative complications.

Results

72 eyes (36 patients) were analysed. No clinically significant difference between pre- and postoperative corrected distance visual acuity (CDVA) was found for monocular or binocular measurements. Mean postoperative monocular CDVA was 0.02 ± 0.04 logMAR. Mean refractive values all improved statistically significantly compared with preoperative baseline (p ≤ 0.0064). Overall, 82.4% of eyes had spherical equivalent within ± 0.5 D and 97.1% within ± 1.0 D of emmetropia with a mean accuracy of -0.10 ± 0.41 D. Spectacle independence for distance, intermediate and near visual acuity was 87.5%, 84.4% and 78.1% respectively, and 78.1% of patients were satisfied with their postoperative, spectacle-free vision. Eight eyes received Nd:YAG laser treatment. No other IOL-related safety issues were reported.

Conclusion

AT LISA tri 839MP multifocal IOL bilaterally implanted in presbyopic patients provided excellent distance, intermediate and near visual outcomes with very accurate correction of refraction. These results were associated with a high level of spectacle independence and patient satisfaction.

Trial registration

Trial registered on https://clinicaltrials.gov/ under the identification NCT03790592 (31/12/2018).

Review of Presbyopia Treatment with Corneal Inlays and New Developments

Presbyopia may represent the largest segment of refractive errors that is without an established and effective refractive surgery treatment. Corneal Inlays are materials (synthetic or allogenic) implanted in the stroma of patients’ corneas to improve presbyopia. These inlays, introduced into the United States in 2015 via the small-aperture corneal inlay (KAMRA^TM, SightLife Surgical/CorneaGen, Seattle, Washington, United States), were met with an initial wave of enthusiasm. Subsequent models like the shape-changing corneal inlay (RAINDROP^TM, Revision Optics, Lake Forest, California, United States) offered excellent results for patients, but longer-term research raised questions about patient safety. At the time of this article, no synthetic corneal inlays are available in the United States for the correction of presbyopia. Other options for presbyopia correction include allograft corneal inlays, trifocal synthetic corneal inlays, pharmacologic therapies, scleral incisions or additive techniques and PresbyLASIK. Presently, allograft inlays consist of corneal lenticules removed from patients undergoing Small Incision Lenticule Extraction (SMILE). We will review corneal inlays and other alternative procedures that may provide effective and predictable treatments for patients with presbyopia.

Understanding In Vivo Chromatic Aberrations in Pseudophakic Eyes Using on Bench and Computational Approaches

Diffractive multifocal intraocular lenses (IOLs) modulate chromatic aberration and reduce it at certain distances due to interactions between the refractive and diffractive chromatic components. However, the extent to which computer modeling and on bench measurements of IOL chromatic aberration translate to chromatic aberration in patients implanted with these multifocal IOLs (MIOLs) is not yet fully understood. In this study, we compare the chromatic difference of focus and longitudinal chromatic aberrations in pseudophakic patients implanted with different IOL designs (monofocal and trifocal IOLs) and materials (hydrophobic and hydrophilic), and compared them with predictions from computer eye models and on bench measurements with the same IOLs. Patient data consisted of results from 63 pseudophakic eyes reported in four different studies and obtained psychophysically in the visual testing channel of a custom-developed polychromatic adaptive optics system. Computational predictions were obtained using ray tracing on computer eye models, and modulation transfer function (MTF) on bench measurements on physical eye models. We found that LCA (in vivo/simulated) for far vision was 1.37 ± 0.08 D/1.19 D for monofocal hydrophobic, 1.21 ± 0.08 D/0.88 D for monofocal hydrophilic, 0.99 ± 0.06 D/1.19 D for MIOL hydrophobic, and 0.82 ± 0.05 D/0.88 D for MIOL hydrophilic. For intermediate and near vision, LCA (in vivo/simulated) was 0.67 ± 0.10 D/0.75 D and 0.23 ± 0.08 D/0.19 D for MIOL hydrophobic and 0.27 ± 0.15 D/0.38 D and 0.15 ± 0.15 D/−0.13 D for MIOL hydrophilic, respectively. In conclusion, computational ray tracing and on bench measurements allowed for evaluating in vivo chromatic aberration with different materials and designs for multifocal diffractive intraocular lenses.

Assessment of a New Trifocal Diffractive Corneal Inlay for Presbyopia Correction Using an Adaptive Optics Visual Simulator

In this work, we analyze a proposal of a new intracorneal diffractive lens for presbyopia correction that could allow good, distance, intermediate and near vision. By using an adaptive optics visual simulator, we study the influence of two factors in the inlay performance: the spherical aberration (SA) and the potential errors of in thickness, induced in the manufacturing process. We show that the inlay through-the-focus imaging performance can be customized with the SA value, favoring either distance–intermediate or intermediate–near vision. Moreover, we found that with thickness variations of 10%, the inlay still maintains its trifocal nature.

Presbyopia Treatments by Mechanism of Action: A New Classification System Based on a Review of the Literature

Presbyopia, a loss of accommodative ability associated with aging, is a significant cause of vision impairment globally. At the clinical level, it is a frustrating and difficult issue that negatively impacts patients’ quality of life. Less appreciated is the fact that loss of accommodative ability and its current treatments methods may present safety concerns, for example, increasing the risk of falls. Therefore, a more complete understanding of treatment options with respect to how they relate to the natural ability of the eye is needed to improve decision making and to aid clinicians in individualizing treatment options. This article reviews the options for expanding functional through focus—a term coined to describe the ability of the eye to see at all distances with minimal latency—by how they vary the refractive power over time, across the visual field, between eyes, or across a range of distances.

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In vivo measurement of the attenuation coefficient of the sclera and ciliary muscle

We acquired 1325 nm OCT images of the sclera and ciliary muscle of human subjects. The attenuation coefficients of the sclera and ciliary muscle were determined from a curve fit of the average intensity profile of about 100 A-lines in a region of interest after correction for the effect of beam geometry, using a single scattering model. The average scleral attenuation coefficient was 4.13 ± 1.42 mm-1 with an age-related decrease that was near the threshold for statistical significance (p = 0.053). The average ciliary muscle attenuation coefficient was 1.72 ± 0.88 mm-1, but this value may be an underestimation due to contributions from multiple scattering. Overall, the results suggest that inter-individual variations in scleral attenuation contribute to variability in the quality of transscleral OCT images of the ciliary muscle and the outcome of transscleral laser therapies.

Improvement of Presbyopia Using a Mixture of Traditional Chinese Herbal Medicines, Including Cassiae Semen, Wolfberry, and Dendrobium huoshanense

Background

Presbyopia is a primary cause of a decline in near vision. In this study, we developed a new mixed herbal medicine to retard presbyopic progression and increase the amplitude of accommodation (AA), which is beneficial for near vision.

Methods

A total of 400 participants between the ages of 45 and 70 years were recruited. We designed the mixed herbal drug to include Cassiae Semen (200 mg), wolfberry (200 mg), and Dendrobium huoshanense (DD) (40 mg) in one capsule. In experiment 1, the recruited subjects were directed to perform a push-up test to measure their AA; this was then converted to the additional diopters of reading glasses. In experiment 2, 240 subjects took three capsules daily for six months and then stopped medical therapy for a six-month follow-up. In experiment 3, 160 subjects were randomly categorized into four groups: a placebo group, low-dose group (LDG) (1 capsule daily), middle-dose group (MDG) (two capsules daily), and high-dose group (HDG) (three capsules daily). The 160 volunteers took different doses for six months and then stopped treatment, accompanied by another six-month follow-up. In experiments 2 and 3, the change in AA, uncorrected far visual acuity (UFVA), and uncorrected near visual acuity (UNVA) were recorded each month for one year.

Results

In experiment 1, AA was found to decrease with age and a great deal of additional power was needed in older individuals. In experiment 2, the mean AA reached a maximum value of 2.1D (P < 0.05) after six months, while the UNVA improved by about two to three lines of a Jaeger chart in most of the subjects. At nine months, all the means decreased slightly to 2.0 D (P < 0.05). This meant that the mixed herbal medicine could still maintain AA for another three months because the herbal therapy was stopped at the seventh month. In experiment 3, the maximal AA was 2.8D, 2.9D, and 3.2D (P < 0.05) in the LDG, MDG, and HDG after six-month treatments, respectively. Experiment 3 showed that AA gain occurred in a dose-dependent manner; the higher the dose, the greater the AA value.

Conclusion

Only two studies on the use of herbal drugs for presbyopia have been reported in PubMed. In our study, we found that taking a mixed herbal drug caused an excellent gain in AA. This is the first study to report that the characteristics of the new herbal regimen could retard and even ameliorate presbyopia.

Sensory Dysfunction in Old Age

BACKGROUND

The senses serve as the crucial interface between the individual and the environment. They are subject to aging and disease processes.

METHODS

This review is based on pertinent publications retrieved by a selective search in the Medline and Cochrane Library databases.

RESULTS

Approximately 40% of persons aged 70 to 79 manifest dysfunction in at least one, and more than 25% in multiple senses. Sensory changes are accompanied by diverse comorbidities which depend on the particular sense(s) affected. The presence of sensory deficits is associated with an increased risk of developing dementia (OR: 1.49 [95% confidence interval: 1.12; 1.98] for dysfunction in a single sensory modality, 2.85 [1.88; 4.30] for dysfunction in three or more sensory modalities). The risk of developing depressive symptoms is elevated as well (OR 3.36 [2.28; 4.96]). The individual's ability to cope with the demands of everyday life is largely determined by the ability to carry out multisensory integration, in which the perceptions of the different senses are bound together. This function itself is subject to age-related changes that can be either adaptive or maladaptive; it can, therefore, serve as an indicator for pathological aging processes.

CONCLUSION

Sensory dysfunction in old age should be detected as early as possible. This implies the need for close collaboration of all of the involved disciplines. It would be desirable to develop sensory screening tests as well as a procedure for testing multisensory integration in routine clinical practice.

Correcting Presbyopia With Autofocusing Liquid-Lens Eyeglasses

OBJECTIVE

Presbyopia, an age-related ocular disorder, is characterized by the loss in the accommodative abilities of the human eye. Conventional methods of correcting presbyopia divide the field of view, thereby resulting in significant vision impairment. We demonstrate the design, assembly and evaluation of autofocusing eyeglasses for restoration of accommodation without dividing the field of view.

METHODS

The adaptive optics eyeglasses comprise of two variable-focus liquid lenses, a time-of-flight range sensor and low-power, dual microprocessor control electronics, housed within an ergonomic frame. Subject-specific accommodation deficiency models were utilized to demonstrate high-fidelity accommodative correction. The abilities of this system to reduce accommodation deficiency, its power consumption, response time, optical performance and MTF were evaluated.

RESULTS

Average corrected accommodation deficiencies for 5 subjects ranged from -0.021 D to 0.016 D. Each accommodation correction calculation was performed in ∼67 ms which consumed 4.86 mJ of energy. The optical resolution of the system was 10.5 cycles/degree, and featured a restorative accommodative range of 4.3 D. This system was capable of running for up to 19 hours between charge cycles and weighed ∼132 g.

CONCLUSION

The design, assembly and performance of an autofocusing eyeglasses system to restore accommodation in presbyopes has been demonstrated.

SIGNIFICANCE

The new autofocusing eyeglasses system presented in this article has the potential to restore pre-presbyopic levels of accommodation in subjects diagnosed with presbyopia.

Multifocal Spectacle and Monovision Treatment of Presbyopia and Falls in the Elderly

Presbyopia is an age-related condition that affects approximately 1.8 billion people worldwide. Strategies to correct presbyopia include both nonsurgical and surgical approaches. Although eye care providers assume that multifocal spectacles and monovision have lower risks than surgical interventions, there is evidence to suggest that the use of these nonsurgical approaches in the older population increases the risk for trips and falls. Each year, fall-related injuries and deaths are reported in a substantial portion of the population, both globally and in the United States. Previous studies have shown a link between visual acuity, contrast sensitivity, stereoacuity, and visual field impairments and falls. More recent mechanistic and epidemiological studies have shown that multifocal spectacles and monovision can increase the risk for falls as well. Although evidence on the financial burden of falls related to multifocal spectacles or monovision is limited, total direct medical costs related to falls associated with multifocal spectacles are estimated to be approximately $11 billion annually in the United States. Therefore, it is important that eye care providers consider the risk for falls associated with multifocal spectacles and monovision when making decisions on the best strategy for correcting presbyopia in older adults. [J Refract Surg. 2021;37(6 Suppl):S12-S16.].

PresbyLASIK: A review of PresbyMAX, Supracor, and laser blended vision: Principles, planning, and outcomes

PresbyLASIK is one of the most commonly used modalities of surgical correction in presbyopes with no cataract. Unlike monovision procedures, both the eyes are adjusted for near and distance, providing a good stereopsis. This works by creating a corneal multifocality and increasing the depth of focus. Most techniques of presbyLASIK currently employ hybrid methods, i.e., a component of monovision added on to a multifocal corneal ablation. Choosing an appropriate proportion of these two components according to the patients' requirements and meticulous patient selection are key to obtaining desirable outcomes. Being corneal-based procedures, presbyLASIK has shown to be reversible. Thorough updated knowledge of the different presbyLASIK procedures, their principles and outcomes based on previous studies is required before a refractive surgeon plans to start providing presbyLASIK services. We performed a comprehensive search on PubMed with the keywords "Presbyopia surgery," "PresbyLASIK" "PresbyMAX," "Supracor," and "Custom-Q." In this review article, we have explained the principles of the various presbyLASIK procedures, appropriate patient selection and planning on the devices with examples, and summarized the previously published outcomes of these techniques.

Simulating Outcomes of Cataract Surgery: Important Advances in Ophthalmology

As the human eye ages, the crystalline lens stiffens (presbyopia) and opacifies (cataract), requiring its replacement with an artificial lens [intraocular lens (IOL)]. Cataract surgery is the most frequently performed surgical procedure in the world. The increase in IOL designs has not been paralleled in practice by a sophistication in IOL selection methods, which rely on limited anatomical measurements of the eye and the surgeon's interpretation of the patient's needs and expectations. We propose that the future of IOL selection will be guided by 3D quantitative imaging of the crystalline lens to map lens opacities, anticipate IOL position, and develop fully customized eye models for ray-tracing-based IOL selection. Conversely, visual simulators (in which IOL designs are programmed in active elements) allow patients to experience prospective vision before surgery and to make more informed decisions about which IOL to choose. Quantitative imaging and optical and visual simulations of postsurgery outcomes will allow optimal treatments to be selected for a patient undergoing modern cataract surgery.

Quantitative analysis of internal components of the human crystalline lens during accommodation in adults

To quantitatively analyze changes in the inner components of the human crystalline lens during accommodation in adults. Eyes of 23 subjects were sequentially examined using CASIA2 Optical Coherence Tomography under 0D, - 3D and - 6D accommodation states. The anterior chamber depth (ACD), anterior and posterior crystalline lens radius of the curvature (ALRC and PLRC) were obtained using built-in software. The lens thickness (LT), lenticular nucleus thickness (NT), anterior cortex thickness (ACT), posterior cortex thickness (PCT), anterior and posterior lenticular nucleus radius of the curvature (ANRC and PNRC), anterior and posterior lenticular nucleus vertex (ANV and PNV) were quantified manually with the Image-pro plus software. During accommodation, the ACD became significantly shallower and LT significantly increased. For changes in the lens, the ALRC decreased by an average magnitude (related to accommodative stimuli) 0.44 mm/D, and PLRC decreased 0.09 mm/D. There was no difference for the ACT and PCT in different accommodation states. For lenticular nucleus response, NT increased on average by 30 μm/D. Both the ANRC and PNRC decreased on average by 212 μm/D and 115 μm/D respectively. The ANV moved forward on average by 0.07 mm under - 3D accommodative stimuli and 0.16 mm for - 6D. However, there was no statistically significant difference between different accommodation states in the PNV movement. Under accommodation stimulation, lens thickness changed mainly due to the lenticular nucleus, but not the cortex. For the lenticular nucleus, both the ANRC and PNRC decreased and ANRC changed the most. The anterior surface of the nucleus moved forward while the posterior surface of the nucleus moved backward but only slightly.

A new trifocal corneal inlay for presbyopia

Corneal inlays (CIs) are the most recent surgical procedure for the treatment of presbyopia in patients who want complete independence from the use of glasses or contact lenses. Although refractive surgery in presbyopic patients is mostly performed in combination with cataract surgery, when the implantation of an intraocular lens is not necessary, the option of CIs has the advantage of being minimally invasive. Current designs of CIs are, either: small aperture devices, or refractive devices, however, both methods do not have good performance simultaneously at intermediate and near distances in eyes that are unable to accommodate. In the present study, we propose the first design of a trifocal CI, allowing good vision, at the same time, at far, intermediate and near vision in presbyopic eyes. We first demonstrate the good performance of the new inlay in comparison with a commercially available CI by using optical design software. We next confirm experimentally the image forming capabilities of our proposal employing an adaptive optics based optical simulator. This new design also has a number of parameters that can be varied to make personalized trifocal CI, opening up a new avenue for the treatment of presbyopia.

Visual performance comparison of 2 extended depth-of-focus intraocular lenses

PURPOSE

To compare the visual acuity and satisfaction outcomes of 2 different concepts of extended depth-of-focus intraocular lenses (EDOF IOLs).

SETTING

University Eye Hospital Bochum, Germany.

DESIGN

Prospective randomized comparative clinical trial.

METHODS

Patients undergoing cataract surgery with the implantation of 2 different concept EDOF IOLs. In the first group (IC-8 Group), a monofocal 1-piece Tecnis Z B00 IOL (Johnson & Johnson Vision Care, Inc.) was implanted in the dominant eye, and an IC-8 IOL (AcuFocus) was implanted in the nondominant eye. In the second group (Symfony Group), a Tecnis Symfony IOL (Johnson & Johnson Vision Care, Inc.) was implanted in both eyes. The target refraction of the dominant eye was emmetropia and slight myopia (mini-monovision, -0.75 diopters) in the nondominant eye. Visual and refractive outcomes and patient satisfaction rates were evaluated 3 months postoperatively.

RESULTS

This study comprised 76 eyes of 38 patients. No intraoperative or postoperative complications occurred in either group. Target refraction was reached in both groups without statistically significant differences. The uncorrected distance visual acuity (UDVA, photopic and mesopic light conditions) was excellent in both groups with statistically significantly better results in the IC-8 goup (logarithm of the minimum angle of resolution; IC-8 Group (0.1 ± 0.07 logarithm of the minimum angle of resolution [logMAR]; Symfony Group 0.07 ± 0.1 logMAR, P value .02 [photopic]; IC-8 group 0.12 ± 0.09 logMAR, Symfony group 0.22 ± 0.1 logMAR, P value < .01 [mesopic]). Binocular uncorrected intermediate visual acuity (UIVA) and uncorrected near visual acuity (UNVA) were also good in both groups without statistically significant differences (UIVA: IC-8 Group, 0.01 ± 0.07 logMAR, Symfony Group 0.01 ± 0.08 logMAR, P value .35; UNVA: IC-8 Group 0.14 ± 0.11, Symfony Group 0.09 ± 0.08, P value .14). Subjective satisfaction was high in both groups.

CONCLUSIONS

Both EDOF IOLs provided a very good UDVA with superior results in the IC-8 Group, and a good UIVA and UNVA under photopic light conditions. Subjective patient satisfaction was higher in the IC-8 Group.

Multifocal acceptance score to evaluate vision: MAS-2EV

We present a new metric (Multifocal Acceptance Score, MAS-2EV) to evaluate vision with presbyopic corrections. The MAS-2EV is based on a set of images representing natural visual scenes at day and night conditions projected in far and near displays, and a near stereo target. Subjects view and score the images through different binocular corrections (monofocal corrections at far; bifocal corrections; monovision and modified monovision) administered with soft contact lenses (in cyclopleged young subjects) or with a binocular simultaneous vision simulator (in presbyopic and cyclopleged young subjects). MAS-2EV scores are visually represented in the form of polygons, and quantified using different metrics: overall visual quality, visual degradation at far, visual benefit at near, near stereo benefit, visual imbalance near-far, overall visual imbalance and a combined overall performance metric. We have found that the MAS-2EV has sufficient repeatability and sensitivity to allow differentiation across corrections with only two repetitions, and the duration of the psychophysical task (3 min for subject/condition/correction) makes it useable in the clinic. We found that in most subjects binocular bifocal corrections produce the lowest visual imbalance, and the highest near stereo benefit. 46.67% of the subjects ranked binocular bifocal corrections first, and 46.67% of the subjects ranked monovision first. MAS-2EV, particularly in combination with visual simulators, can be applied to select prospective presbyopic corrections in patients prior to contact lens fitting or intraocular lens implantation.

Clinical and Surgical Outcome of a Supplementary Multifocal Intraocular Lens Implanted with a Bag-In-the-Lens Intraocular Lens: 5-Year Follow-Up

INTRODUCTION

To assess the postoperative outcome and patient-reported satisfaction, spectacle independence, and dysphotopsia after implantation with the mutifocal Rayner Sulcoflex supplementary intraocular lens (sIOL).

MATERIALS AND METHODS

We analyzed the outcome of all patients implanted with a multifocal sIOL between 2009 and 2011. In all cases, the sIOL was the Rayner Sulcoflex IOL (type 653F) and the primary IOL was a bag-in-the-lens (BIL) IOL. The data were obtained through a retrospective analysis of the patient records and by means of a questionnaire, 5 years after sIOL implantation.

RESULTS

This study included 31 eyes of 20 patients. In 13 eyes, the sIOL needed explantation (n = 13, 41.94%). Dysphotopsia is a frequent complaint (12/15 patients: 80.0%) after sIOL implantation. In 13 out of 31 eyes (41.94%), pigment deposits were found on the sIOL with variable clinical complaints. Five eyes required additional surgery because of clinically significant deposits.

DISCUSSION/CONCLUSION

Patients with a multifocal sIOL in combination with a BIL implantation have a higher incidence of dysphotopsia compared to previously published studies. Dysphotopsia was the main complaint and reason for explantation. We encountered a high incidence of pigmented IOL deposits. The sIOLs can be safely removed even years after implantation.

A preliminary study on the visual outcomes after LaserACE for presbyopia

Background

To investigate the visual outcomes over 1 year after laser anterior ciliary excision (LaserACE) procedure for presbyopic subjects.

Methods

A prospective, non-randomized, non-comparative study. Eight emmetropic eyes of four patients with presbyopia were included in this study. All eyes were treated with the LaserACE procedure using the VisioLite erbium-YAG laser (Ace Vision Group, USA). Subjects were assessed preoperatively and at 1 day, 1 week, 1 month, 3 months, 6 months, and 1 year postoperatively. Outcome measures included questionnaires, visual acuity, manifest refraction, pupil size, keratometry, reading prescription, and intraocular pressure.

Results

Binocular distance corrected intermediate visual acuity (DCIVA) had improved from 0.33±0.12 logMAR to 0.12±0.12 logMAR after 6 months (P<0.05) and 0.13±0.12 logMAR after 12 months postoperatively (P<0.01). Binocular distance corrected near visual acuity (DCNVA) improved from 0.41±0.10 logMAR to 0.24±0.12 logMAR after 6 months (P<0.05) and 0.26±0.09 log MAR after 12 months postoperatively (P<0.05). An average decrease of 0.91±0.28 D in the reading prescription at a 40 cm reading distance was observed and remained stable over 12 months (P<0.05). There were no significant differences in manifest refraction, uncorrected distance visual acuity (UDVA), corneal curvature, high order aberrations, pupil size compared with preoperative and 6 months as well as 12 months postoperative visits (P>0.05).

Conclusions

The LaserACE procedure is shown to be safe and efficient for presbyopia correction without influencing distance vision or visual quality. However, its mechanism and long-term effects need further validation.

Correction of pseudophakic presbyopia using Lasik with aspheric ablation profiles and a micro-monovision protocol

PURPOSE

To evaluate the outcomes of Lasik with aspheric ablation profiles and a micro-monovision protocol for correction of presbyopia in pseudophakic patients.

PATIENTS AND METHODS

This study included 50 pseudophakic eyes of 25 patients. Full ophthalmic examination, dominant eye tests and tests for tolerance of anisometropia (1 or 2 diopters) were done preoperatively. All cases were treated by Lasik with laser-blended vision technique. The dominant eye corrected to plano, and the nondominant eye corrected with near add in the range from 1.50 to 2.00 diopters. Excimer laser ablation was done using the MEL90 with a 250-Hz pulse rate (Carl Zeiss Meditec, Jena, Germany, Triple-A profile, Lasik mode). The follow-up period was 6 months with visits at 1, 3 and 6 months postoperatively.

RESULTS

The mean postoperative uncorrected distant visual acuity at 1 month (0.74 ± 0.11) was significantly lower than the preoperative level (0.84 ± 0.14) (p < 0.001). But it improved at the 3rd (0.80 ± 0.09) and 6th months (0.82 ± 0.10) with no significant difference with the preoperative level (p = 0.344). The mean uncorrected near visual acuity was significantly higher at the 1st (2.94 ± 1.63 J), 3rd (2.95 ± 1.82 J) and 6th (2.92 ± 1.83 J) postoperative months than the preoperative level (2.26 ± 1.48 J) (p < 0.001). Insignificant change in stereopsis was found after surgery (p = 0.849). The micro-monovision was well tolerated (95.8%).

CONCLUSION

Lasik with aspheric ablation profiles and a micro-monovision protocol is an effective option for presbyopia correction in pseudophakic patients.

Diffractive multifocal intraocular lens implantation in patients with monofocal intraocular lens in the contralateral eye

AIM

To evaluate clinical outcomes of unilateral implantation of a diffractive multifocal intraocular lens (IOL) in patients with contralateral monofocal IOL.

METHODS

Twenty-two patients who already had implantation of a monofocal IOL in unilateral eye underwent implantation of a diffractive multifocal IOL in contralateral eye were enrolled. After 1, 6, and 12mo, uncorrected and distant corrected distant visual acuity (UCDVA and DCDVA), uncorrected and distant corrected intermediate-visual acuity (UCIVA and DCIVA), uncorrected and distant corrected near visual acuity (UCNVA and DCNVA), and contrast sensitivity were obtained. Halo/glare symptoms, spectacle dependence, and patient satisfaction were also evaluated.

RESULTS

The mean age was 67.86±7.25y and the average interval between two IOL implantations was 645.82±878.44d. At 1mo, binocular UCDVA was lower than 0.20 logMAR in 76% of patients (mean 0.12±0.13 logMAR), which increased to 90% by 6 and 12mo. The binocular UCDVA was significantly better than the monocular results (P<0.05) at 1, 6, and 12mo. Additionally, UCNVA was lower than 0.40 logMAR in 82% of patients, increasing to 90% by 6 and 12mo. Mean UCNVA in the multifocal IOL implanted eye was statistically significantly better than that in the monofocal IOL implanted eye (P<0.05) at 1, 6, and 12mo. About 5% of patients at 1 and 6mo, reported "severe glare or halo". Patient satisfaction rates were 95% and 91% at 6 and 12mo, respectively.

CONCLUSION

Unilateral implantation of multifocal IOL in patients with a contralateral, monofocal IOL implantation results in high patient satisfaction rate, with low severe glare or halo rate during follow-up. It can represent a good option for patients who have previously had a monofocal IOL implantation regardless of two year interval duration between two IOL implantations.

Proposal of a new diffractive corneal inlay to improve near vision in a presbyopic eye

A new class of diffraction-based corneal inlays for treatment of presbyopia is described. The inlay is intended to achieve an improvement of the near focus quality over previous designs. Our proposal is a two-zone hybrid device with separated amplitude and phase areas having a central aperture and no refractive power. An array of micro-holes is distributed on the surface of the inlay conforming a binary photon sieve. In this way, the central hole of the disk contributes to the zero order of diffraction, and the light diffracted by the micro-holes in the peripheral photon sieve produces a real focus for near vision. We employed ray-tracing software to study the performance of the new inlay in the Liou-Brennan model eye. The modulation transfer functions (MTFs) at the distance and near foci, and the area under the MTFs for different object vergences, were the merit functions used in the evaluation. The results were compared with those obtained with previous pure amplitude designs. Additionally, image simulations were performed with the inlays in the model eye to show the good performance of our proposal in improving the quality of the near vision.

Optimization of the Light Sword Lens for Presbyopia Correction

Purpose

We propose and evaluate the modifications of a light sword lens (LSL) to obtain better performance for distance vision while maintaining good operation for near and intermediate vision.

Methods

The modifications consisted of assigning angular or circular windows for distance vision while rescaling the LSL profile in the remaining area of the element. The objective performance of the redesigned LSLs was verified numerically by the Strehl ratio and experimentally using correlation coefficients and Michelson contrast. Subjective assessments were provided by monocular visual acuity (VA) and contrast sensitivity (CS) through-focus curves for six patients with paralyzed accommodation. The tested object vergence range was [-4.0, 0.0] diopters (D). All experiments were conducted in a custom-made monocular visual simulator.

Results

Computational simulations and objective experiments confirmed the better performance of the modified LSL for the imaging of distant objects. The proposed angular and radial modulations resulted in flat VA and CS through-focus curves, indicating more uniform quality of vision with clearly improved distance vision. The VA provided by the modified LSL profiles showed a maximal improvement of 1.5 lines of acuity with respect to the VA provided by the conventional LSL at distance vision.

Conclusions

Optimized LSLs provide better imaging of distant objects while maintaining a large depth of focus. This results in comparable and acceptable quality for distance, intermediate, and near vision. Therefore, the modified LSLs appear to be promising presbyopia correctors.

Translational Relevance

The new design of LSL reveals an improved performance for all ranges of vision and becomes a promissory element for a real presbyopia correction in clinical applications.

Optical Evaluation of New Designs of Multifocal Diffractive Corneal Inlays

Purpose

To assess the imaging properties of two different designs of a new concept of corneal inlays whose working principle is based on diffraction.

Methods

The quality of the retinal images provided by Diffractive Corneal Inlays (DCIs) was evaluated theoretically in comparison with Small Aperture Corneal Inlay (SACI). ZEMAX OpticStudio software was employed for the simulations in an eye model with different pupil diameters (3.0 mm and 4.5 mm). The employed merit functions in the analysis were the Modulation Transfer Function (MTF), the area under the MTF (MTFa), and the Point Spread Function (PSF). Comparison was made with the SACI at different defocus conditions.

Results

The bifocal nature of the DCIs was demonstrated in a model eye for the first time. It was shown that the intensity of the near focus depends on the radius of the central zone. Retinal image quality of the DCI was equal to or exceeded the SACI in the majority of visual conditions as was demonstrated with simulated images.

Conclusions

A new customizable type of corneal inlays has been evaluated using objective numerical simulations. Improvements in imaging of near objects and in light throughput compared with the popular small aperture inlays were demonstrated. These findings open a new technical branch of minimally invasive surgical solutions for the treatment of presbyopia.

Pre-operative simulation of post-operative multifocal vision

While multifocal intraocular lenses (MIOLs) are increasingly implanted to correct for presbyopia, how one sees with a multifocal correction is hard to explain and imagine. The current study evaluates the quality of various visual simulating technologies by comparing vision with simulated MIOLs pre-operatively and the implanted MIOLs post-operatively in the same patients. Two simulation platforms were used: (1) a custom-developed adaptiveoptics (AO) system, with two visual simulator devices: a spatial light modulator (SLM) and an optotunable lens operating under temporal multiplexing (SimVis); and (2) a wearable, binocular, large field of view SimVis2Eyes clinical simulator (SimVis Gekko, 2Eyes Vision, Madrid, Spain). All devices were programmed to simulate a trifocal diffractive MIOL (POD F, FineVision, PhysIOL). Eight patients were measured pre-operatively simulating the trifocal lens and post-operatively with implantation of the same MIOL. Through-focus decimal visual acuity (TF VA) was measured (1) monocularly in monochromatic light using a four-alternative-forced-choice procedure in the AO system; and (2) binocularly using a clinical optotype in white light. Visual simulations pre-operatively predict well the TF VA performance found post-operatively in patients implanted with the real IOL. The average RMS difference between TF curves with the different visual simulators was 0.05 ± 0.01. The average RMS difference between the TF VA curves with the SimVis pre-operatively and the real MIOL post-operatively was 0.06 ± 0.01 in both platforms, and it was higher in cataract eyes (0.08 ± 0.01, on average across simulators) than in eyes with clear lens. In either group the shape of the TF curves is similar across simulators and pre- and post-operatively. TF curves cross-correlated significantly between simulators (lag k = 0, rho = 0.889), as well as with results with the real MIOL implanted (lag k = 0, rho = 0.853). Visual simulations are useful programmable tools to predict visual performance with MIOLs, both in an AO environment and in a clinical simulator. Pre-operative visual simulations and post-operative data are in good agreement.

One-year clinical evaluation of rotationally asymmetric multifocal intraocular lens with +1.5 diopters near addition

We conducted a one-year prospective, multicenter study to assess clinical outcomes after implantation of segmented, rotationally asymmetric multifocal intraocular lenses (IOLs) with +1.5 diopters (D) near addition. In this phase III clinical trial, 120 eyes of 65 patients undergoing phacoemulsification and implantation of Lentis Comfort LS-313 MF15 (Oculentis GmbH) were included. The ophthalmological examinations were performed before and 1 day, 1 week, 1, 3, 6, 9, and 12 months after surgery. Uncorrected (UDVA) and corrected (CDVA) distance visual acuity, uncorrected (UIVA) and distance-corrected (DCIVA) intermediate visual acuity at 70 cm, and uncorrected (UNVA) and distance-corrected (DCNVA) near visual acuity at 30 cm were measured. A defocus curve was obtained and patients were asked about the severity of photic phenomena. Postoperative distance and intermediate visual acuity was excellent, with UDVA, CDVA, UIVA, and DCIVA of approximately 20/20, 20/16, 20/25, 20/25 were attained, respectively. The level of near visual acuity was lower; UNVA and DCNVA remained at around 20/60 and 20/70, respectively. The defocus curve indicated that postoperative uncorrected visual acuity of 20/25 and 20/40 was obtained at as close as 67 cm and 50 cm, respectively. Contrast sensitivity was within the normal range, with a minimal level of subjective symptoms and high patient satisfaction. The rotationally asymmetric multifocal IOLs with +1.5 D near addition provided excellent distance and intermediate vision, but near vision was not enough for reading small prints. Contrast sensitivity was high, with very low incidences of photic phenomena and a high level of patient satisfaction.

Vision with different presbyopia corrections simulated with a portable binocular visual simulator

Presbyopes can choose today among different corrections to provide them with functional vision at far and near, and the outcomes and patient satisfaction depend on the selection. In this study, we present a binocular and portable vision simulator, based on temporal multiplexing of two synchronized tunable lenses allowing see-through and programmable visual simulations of presbyopic corrections. Seventeen binocular corrections were tested: 3 Monofocal (Far, Intermediate, Near), 4 Simultaneous Vision (bifocal, trifocal), 2 Monovision (far and near in either eye) and 8 Modified Monovision corrections (Simultaneous vision in one eye, Monofocal in the other eye). Perceived visual quality was assessed through the simulated corrections in 8 cyclopleged subjects who viewed a composite realistic visual scene with high contrast letters and a landscape at far (4 m) and a high contrast text at intermediate (66 cm) and near (33 cm) distances. Perceptual scores were obtained on a scale of 0 to 5 (low to high perceived quality). Perceptual preference was assessed by judging 36 random image pairs (6 repetitions) viewed through 9 binocular presbyopic corrections using two-interval forced choice procedures. The average score, across far and near distances, was the highest for Monovision (4.4±0.3), followed by Modified Monovision (3.4±0.1), Simultaneous Vision (3.0±0.1) and Monofocal corrections (2.9±0.2). However, the mean difference between far and near was lower for Simultaneous Vision and Monovision (0.4±0.1 PS) than Modified Monovision (1.8±0.7) or monofocal corrections (3.3±1.5). A strong significant correlation was found between the perceptual scores and the percentages of energy in focus, for each correction and distance (R = 0.64, p<0.0001). Multivariate ANOVA revealed significant influence of observation distances (p<10-9) and patients (p = 0.01) on Perceptual Score. In conclusion, we have developed a binocular portable vision simulator that can simulate rapidly and non-invasively different combinations of presbyopic corrections. This tool has applications in systematic clinical evaluation of presbyopia corrections.

Prospective comparative study of tolerance to refractive errors after implantation of extended depth of focus and monofocal intraocular lenses with identical aspheric platform in Korean population

Background

To evaluate the clinical outcomes of extended depth of focus (EDOF) and monofocal intraocular lenses (IOLs) that share identical aspheric platform and compare their visual acuity tolerance to postoperative refractive errors.

Methods

This non-randomized, prospective comparative study included 120 eyes undergoing cataract surgery with implantation of either Tecnis ZCB00 IOL (Abbott Medical Optics Inc., Santa Ana, CA) (monofocal group: 60 eyes of 30 patients) or Tecnis Symfony IOL (Abbott Medical Optics, Inc.) (EDOF group: 60 eyes of 30 patients). Monocular and binocular visual outcomes, changes in refraction, defocus curve, contrast sensitivity, and perception of photic phenomena (Halo & Glare Simulator; Eyeland Design Network, Vreden, Germany) were evaluated 3 months postoperatively. To compare the refractive tolerance, each group was divided into three subgroups according to the postoperative uncorrected distance visual acuity (UDVA) and postoperative spherical equivalent (SE).

Results

In the EDOF group, the mean 3-months postoperative monocular UDVA, intermediate (UIVA), and near (UNVA) visual acuities were 0.03 ± 0.07, 0.09 ± 0.15, and 0.24 ± 0.16 logMAR, respectively. A total of 100, 96.55, and 68.97% of eyes in the EDOF group achieved binocular UDVA, UIVA, and UNVA values of 0.20 logMAR or better, respectively. In respect to refractive tolerance, the EDOF group showed higher SE values and statistically significantly better mean UDVA than the monofocal group in all subgroups, with UDVA of − 0.013 and 0.028 logMAR for EDOF and monofocal groups (p = 0.037), respectively, in the subgroup where SE was within ±0.50 D, UDVA of 0.004 and 0.048 logMAR for EDOF and monofocal groups (p = 0.046), respectively, in the subgroup where SE was within − 1.00 D, and UDVA of 0.020 and 0.083 logMAR for EDOF and monofocal groups (p = 0.026), respectively, in the subgroup where SE was more than − 1.00 D. The mean patient satisfaction scores for spectacle-free distance, intermediate, and near visual acuities were 86.0, 85.0, and 66.0, respectively.

Conclusions

The EDOF IOL provided excellent postoperative visual outcomes in far and intermediate distances, with high patient satisfaction rate. Regarding the postoperative refractive tolerance to SE, the Tecnis Symfony IOL showed better tolerance to residual postoperative refractive error than the monofocal IOL with the same material and optical platform.

Autofocals: Evaluating gaze-contingent eyeglasses for presbyopes

As humans age, they gradually lose the ability to accommodate, or refocus, to near distances because of the stiffening of the crystalline lens. This condition, known as presbyopia, affects nearly 20% of people worldwide. We design and build a new presbyopia correction, autofocals, to externally mimic the natural accommodation response, combining eye tracker and depth sensor data to automatically drive focus-tunable lenses. We evaluated 19 users on visual acuity, contrast sensitivity, and a refocusing task. Autofocals exhibit better visual acuity when compared to monovision and progressive lenses while maintaining similar contrast sensitivity. On the refocusing task, autofocals are faster and, compared to progressives, also significantly more accurate. In a separate study, a majority of 23 of 37 users ranked autofocals as the best correction in terms of ease of refocusing. Our work demonstrates the superiority of autofocals over current forms of presbyopia correction and could affect the lives of millions.

Small-aperture optics for the presbyope: do comparable designs of corneal inlays and intraocular lenses provide similar transmittances to the retina?

The near-vision performance of emmetropic presbyopes can be improved by the monocular surgical implantation of small-aperture corneal inlays or intraocular lenses that contain either an annular or circular stop to increase ocular depth of focus. Ray tracing is used to show that, although different stop designs and positions may produce similar axial imagery and increases in depth of focus, off-axis, the vignetting effects associated with the distance between the stop and the iris aperture result in different field dependences for the pupil transmittance. The implications of these effects, and of implanting a stop in only one eye, are discussed.

Fast Measure of Visual Acuity and Contrast Sensitivity Defocus Curves with an iPad Application

Objective:

To evaluate the repeatability of the fast measurement of the visual acuity (VADC) and contrast sensitivity (CSDC) defocus curves with a new test as well as the agreement of measurements at far distance obtained with the Early Treatment Diabetic Retinopathy Study (ETDRS) chart and the ClinicCSF test for measuring Contrast Sensitivity Function (CSF).

Method:

Records from fifty-nine subjects implanted with Multifocal Intraocular Lenses (MIOLs) were retrieved from our database. VADC and CSDC were measured from +1.00 D to -4.00 D in 0.50 D steps. The agreement with the ETDRS and the CSF at far distance was assessed in comparison to the 0 D location of the VADC and the CSDC, respectively. The repeatability was evaluated in 34 subjects who consecutively repeated two measures.

Results:

Median Visual Acuity (VA) was -0.1 logMAR with the VADC at 0 D of defocus and 0 logMAR with the ETDRS (p>0.05). A total of 45.8% of eyes showed no differences between both tests and the difference was less than one line of VA in 96.6% of the eyes. The intrasubject repeatability was under one line of VA along all the defocus curve except for positive defocus levels. The CSDC showed the best agreement with the CSF for 18 cycles per degree. The CSDC was less repeatable than VADC. Mean time spent on completing the VADC and CSDC was 7.81 and 7.98 minutes, respectively.

Conclusion:

The VADC showed good agreement with the ETDRS and good repeatability despite the short testing time. In contrast, poorer repeatability was found for CSDC. Our method would facilitate the inclusion of VADC in clinical practice as it is a fast test, being also the first one including the measure of CSDC.

Visual simulators replicate vision with multifocal lenses

Adaptive optics (AO) visual simulators based on deformable mirrors, spatial light modulators or optotunable lenses are increasingly used to simulate vision through different multifocal lens designs. However, the correspondence of this simulation with that obtained through real intraocular lenses (IOLs) tested on the same eyes has not been, to our knowledge, demonstrated. We compare through-focus (TF) optical and visual quality produced by real multifocal IOLs (M-IOLs) -bifocal refractive and trifocal diffractive- projected on the subiect's eye with those same designs simulated with a spatial light modulator (SLM) or an optotunable lens working in temporal multiplexing mode (SimVis technology). Measurements were performed on 7 cyclopleged subjects using a custom-made multichannel 3-active-optical-elements polychromatic AO Visual Simulator in monochromatic light. The same system was used to demonstrate performance of the real IOLs, SLM and SimVis technology simulations on bench using double-pass imaging on an artificial eye. Results show a general good correspondence between the TF performance with the real and simulated M-IOLs, both optically (on bench) and visually (measured visual acuity in patients). We demonstrate that visual simulations in an AO environment capture to a large extent the individual optical and visual performance obtained with real M-IOLs, both in absolute values and in the shape of through-focus curves.

Adaptation to Brightness Perception in Patients Implanted With a Small Aperture

PURPOSE

Small apertures are successfully used to extend depth of focus in presbyopic patients implemented either as corneal inlays or intraocular lenses. The use of small apertures reduces retinal illuminance. In this study, we quantify the relative perceived brightness in the 2 eyes of patients implanted monocularly with a small-aperture inlay.

DESIGN

Prospective case series.

METHODS

We used a binocular adaptive optics vision simulator to determine the relative perceived brightness. Four patients implanted monocularly with the KAMRA corneal inlay (1.6 mm) and a group of control subjects participated in the study. The projected pupil on the eye implanted with the inlay alternated in diameter between 0 and 2.5 mm (effective 1.6 mm) to eliminate potential for light to project around the periphery of the inlay while the corresponding fellow eye projected pupil alternated between 0 and 3.0 mm or 0 and 4.0 mm at a frequency of 1 Hz. Alternation on both eyes was synchronized so that only 1 eye at a time had a nonblocked pupil. At equal transmittance, a flickering was perceived. Patients' task consisted of modifying the transmittance of the pupil corresponding to the fellow eye until the perceived flickering, owing to the different perceived brightness, was minimized. This equalizing transmittance (ET) value indicates the relative perceived brightness.

RESULTS

In the KAMRA's patients, ET was found to be greater than expected considering the difference in pupil sizes and the Stiles-Crawford effect, showing an enhanced a greater brightness perception in the eye with the small aperture in comparison with the fellow eye. Compared with the control subjects, this difference was on average bigger by a factor of ×1.42.

CONCLUSIONS

Patients implanted with the small-aperture corneal inlay exhibited an enhanced brightness perception with the eye implanted, in comparison with their untreated fellow eye. The amount of this increase is much larger than what could be expected owing to the Stiles-Crawford effect and was probably attributable to a neural adaptation process. This phenomenon could explain a reported equalization of brightness between eyes in patients with unilateral inlays and implies that the expected reduction of brightness may have a less significant impact on these patients, as expected.